The actual measure will be calculated as follows:
Denominator: Number of stays during the reporting period (usually 1 year), with a SNF PPS Part A Discharge Assessment (A0310H = 1). A stay is defined as the period of time from admission/reentry to the facility up to the actual discharge from the Part A stay.
Numerator: The number of residents who experienced one or more major falls that resulted in a major injury during the stay.
To determine which residents that will be included in the numerator all scheduled PPS assessments, OBRA Assessments, Discharge Assessments and SNF PPS Part A Discharge Assessment will be reviewed. This is known as the look back scan.
Example: A facility has a total of 250 SNF Part A stays during a 12-month period, this would represent the denominator. Of these stays, there were 10 documented falls with Major Injury in J1900C of one of the eligible assessments in the look back scan.
This would be represented as a fraction as shown here:
10 Falls w/ Major Injury (J1900C)
250 Part A PPS Stays
To express this as a percentage you would divide the numerator by the denominator, and then multiply by 100.
10/250 x 100 = 4%
This would represent the percentage of residents who experienced a fall with Major Injury during this particular reporting period. There are no risk adjustments for this particular measure.